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Early gastric cancers are asymptomatic in up to 80% of cases. When symptoms do occur, they tend to mimic peptic ulcer disease. With advanced gastric cancer, the most common symptoms are weight loss (≈60% of patients) and abdominal pain (≈50%).298 Other presenting symptoms include nausea, vomiting, anorexia, dysphagia, melena, and early satiety. Pyloric outlet obstruction can occur with tumors of the antrum and pylorus, and tumors of the cardia can cause dysphagia due to involvement of the lower esophageal sphincter and development of pseudoachalasia (see Chapter 43).299 Rarely, paraneoplastic syndromes occur. There have been reports of thrombophlebitis (Trousseau’s sign), neuropathies, nephrotic syndrome, and DIC.300-302 Dermatologic paraneoplastic syndromes are also uncommon and include hyperpigmented patches in the axilla (acanthosis nigricans; see Chapter 24) and the sudden onset of seborrheic dermatosis (senile warts) and pruritus (sign of Leser-Trélat).303
The physical exam is usually unremarkable. Cachexia and signs of bowel obstruction are the most common abnormal findings. Occasionally it is possible to detect an epigastric mass, hepatomegaly, ascites, and lower extremity edema.304 Laboratory studies are generally unrevealing until the cancer reaches advanced stages. Anemia and a positive test result for fecal occult blood may occur from chronic bleeding of an ulcerated mass. Hypoproteinemia can occur. Liver enzyme values, particularly serum alkaline phosphatase levels, can be elevated secondary to hepatic metastases.
Gastric cancer is metastatic at the time of diagnosis in 33% of cases.305 The most common sites of metastasis are the liver (40%) and peritoneum.306 Other sites of spread include periumbilical lymph nodes (Sister Joseph’s nodule), left supraclavicular sentinel nodes (Virchow’s node), the pouch of Douglass (rectal shelf of Blumer), and the ovaries (Krukenberg’s tumor). Gastric cancer has also been reported to metastasize to the kidney, bladder, brain, bone, heart, thyroid, adrenal glands, and skin.304 There are reports of unusual presentations of metastatic disease, such as shoulder-hand syndrome from bone metastasis, diplopia and blindness from orbital and retinal metastases, and virilization due to Krukenberg’s tumors.307-310